Nutrition and Chronic Disease: A Global Perspective PDF

Nutrition and Chronic Disease: A Global Perspective Learning Objectives n Demonstrate knowledge of chronic disease (non- communicable disease) incidence globally and in Canada compared to other causes of mortality a...

Nutrition and Chronic Disease: A Global Perspective Learning Objectives n Demonstrate knowledge of chronic disease (non- communicable disease) incidence globally and in Canada compared to other causes of mortality and morbidity. n Demonstrate an understanding of nutrition transition, focus on a cause and effects, and double-triple burden of globalization disease. n Discuss the strategies and role of nutrition to reduce chronic disease in Canada and globally 3 Diet, Nutrition and Health n Diet and nutrition are essential and fundamental factors in metabolism, physiology, growth, maintenance and promotion of health throughout the entire life span. n Link between diet and health Diet and Nutrition Assessment ⇒ Impact of malnutrition on health Impact of overnutrition on health n Role of diet as a determinant of non-communicable disease/chronic disease (CD) is well established from animal, case-control and supported by large epidemiological studies. 6 1 Links between Diet & Chronic Disease : high intakea fat i CUD High · Caloric · Low fibre & colon Cancer · Calcium & Vit. D & Osteoporosis · Antioxidants (Vit C , , E.... ) & Cancer · Folate B12 Blo & CVD , , Key Facts of Non-Communicable Disease/Chronic Disease Die from non- communicable diseases ↓ Mortality of 41 million people each year, equivalent to 74% of all deaths globally 17 million people die from a NCD before age 70; 86% of these premature deaths occur in low- and middle-income countries 80% of all deaths are from CVD (18 million), cancers (9.3 million), chronic respiratory disease (4.1 million) and diabetes (2 million) WHO: https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases 8 20% Approx. communicable diseases Approx. Sol of pop'n from suffer non-coes! ↑ Remained constant https://www.who.int/publications/i/item/9789240094703 9 2  - Leading Global Causes of Mortality: Communicable, Non-Communicable Diseases and Injuries can combine because related both to atherosclerosis ! S * Related to tobaco & * Alcohol Smoking consumption * moves up every year ! Recard ( WHO 2024 11 Global Causes of Death: Communicable, Non-Communicable Diseases and Injuries ↑ less higher income = non-communicable diseases ! AFR:Africa, AMR: Americas, EMR: East Mediteranean, EUR: Europe, SEAR; South East Asia, WPR: Western Pacific LIC:low income country, LMIC: lower-middle income country, UMIC:upper middle income country, HIC: high income country 12 3  Characteristics of Non-Communicable Disease/Chronic Disease Complex interaction of risk factors Alzheimers ! Noncontiguous origin (no specific exposure) ↓ really help Nutrition Can ! A long latent period between risk factor exposure (subclinical disease), presentation of symptoms, clinical diagnosis, stages of disease early to end-stage disease A long period of illness Multiple risk factor etiology 13 NCD: Risk factors can inhibit abs. of nutrients !/ - Affect other nutrition * /Biological Sex · Food supply ! - ↳ be might not able to eat properly were it ! Which of these are related to diet-nutrition-food system? Budreviciute et al 2020 14 4  NCD: Risk factors * Recommended ZERO - Alcohol intake ! for Especially Cancer (throat , Esophageal.... 15 Leading Causes of Mortality in Low-Income Countries Communicable vs NCD & shows low income countries have m o re of the communicable diseases ! ex : malaria WHO 2024 17 5  Question? n What are the major chronic diseases in developed countries?? 19 Leading Causes of Mortality in High-Income Countries, Communicable vs NCD E both & More 2 These D: non-communicable ! WHO 2024 21 6  Probability of Death from Non-Communicable Diseases of Canadians will Sweden:8.2% 10 % CVD Cancer , diabetes,... die from , ! from 30-70 yrs Canada:9.62% Russia:24.2% Mongolia/ (8.1-11.2%) Afghanistan/Central African Republic/ United Somalia:35% Kingdom:10.1% USA:13.2% China:16.05% (12-20.3%) Iran:14.9%% Chad:24.% Saudi Arabia: 14.3% Algeria :14% (9.7-20.2%) South Africa 21% India 23.7% (19.9-29.2%) Brazil:15.1% Australia 9.0% South Africa:24% (7.2-10.5%) 24 & China & India. Populationissodenser risk of death ! 25 7  Note : US isstill a o 26 27 8 28 Have not met them ! -- WHO SDG 30 9  Global Causes of Disability: Communicable, Non-Communicable Diseases and Injuries NCD greatest years lived with disability. YLD: years lived with disability 32 Leading Level 3 causes of age-standardised DALY rates by location, all ages, both sexes, in 2021. Lancet 2024. Global Burden of Disease Study - - 33 10  (2) (2) Figure 4.5 Global 40 Obesity is not listed as a chronic disease ! 30 know it is in top 10 %! 20 Should be included ! 10 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 Canada included ! d - 40 30 20 10 0 1990 1994 1998 2002 2006 2010 2014 2018 2022 1990 1994 1998 2002 2006 2010 2014 2018 2022 1990 1994 1998 2002 2006 2010 2014 2018 2022 1990 1994 1998 2002 2006 2010 2014 2018 2022 1990 1994 1998 2002 2006 2010 2014 2018 2022 1990 1994 1998 2002 2006 2010 2014 2018 2022 Source In 2022, 2.5 billion adults (2) were overweight, including 890 million who were living with obesity Vs 390 million were underweight. 34 Other chronic diseases? forget * We often these ones! 71 IBS https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310009601 (Health Characteristics 2022) Health Fact Sheets Chronic Conditions, 2017. Statistics Canada 35How to cite: Statistics Canada. Table 13-10-0096-01 Health characteristics, annual estimates, inactive DOI: https://doi.org/10.25318/1310009601-eng https://www150.statcan.gc.ca/n1/pub/82-625-x/2018001/article/54983-eng.htm 11  Other chronic diseases? Health Fact Sheets Chronic Conditions, 2017. Statistics Canada 36https://www150.statcan.gc.ca/n1/pub/82-625-x/2018001/article/54983-eng.htm Leading Causes of Death in Canada > - Leading Cause of Death 201 20 Deaths 2023 Deaths = 5 22 334,081 326,215 Malignant Neoplasms [C00-C97] 1 1 82,412 1 84,629 (cancer-all types Diseases of Heart [I100-I151] 2 2 57,357 2 COVID-19 3 19,716 6 7,963 Accidents (unintentional injuries) 4 18,365 3 20,597 ↳ Std Globally. Cerebrovascular Disease [I60-69] 3 5 13, 915 4 13,833 Chronic Lower Respiratory Disease 4 6 12,462 5 12,994 [J40-J47] Diabetes Mellitus [E10-E14] 7 7 7,557 7 7,273 ↑) Influenza/Pneumonia [J09-J18] 6 8 5,985 8 6393 Alzheimer’s Disease [G30] 8 9 5,413 9 5,231 (including relaa dementia) night Intentional Self Harm (suicide) 9 13 3,593 12 3,811 Nephritis/Nephrotic 11 11 4,234 11 4,106 Syndrome/Nephrosis Statistics Canada 2024 Chronic liver disease/Cirrhosis [K70-74] 10 10 4,530 10 4,374 37 12  Canadian Health Characteristics, Annual Estimates * * * report * * 19 million ! * a BMI of overweight Canada only 41 million So that is half the pop in !! * * * * * Statcan 38 https://www150.statcan.gc.ca/n1/pub/82-625-x/2018001/article/54983-eng.htm Global Dietary Burden Double burden of malnutrition and overnutrition Triple Burden with micronutrient deficiency AND Obesity malnutrition - related def Quadruple if add infectious disease micronut. YouthSays Undernutrition (PEM) = childhood stunting or wasting, and micronutrient deficiencies > 1/3 of all child deaths 50 13  Malnutrition = deficiency, excess or imbalance in energy intake and/or nutrients Undernutrition= wasting (low wt-for-ht), stunting (low ht-for-age), underweight (low st- for-age) Micronutrient-related malnutrition associated with deficiency in essential vitamins- minerals or micronutrient excess Overweight/obesity and diet related non- communicable disease (CVD, diabetes, some cancers) https://www.who.int/news-room/fact-sheets/detail/malnutrition * 52 D malnutrition 6 Top : Suboptimal BFing , , overnutrition, Thyroid Overall metabolism affected ! lodine def. = = Vit & overall health (protection-Skin resp , repro... ) , function growth A def = Vision int.. , , WHO 54 14  Still prevalence & of stunting ! wasting Co Chronic malnutrition -low SES, social determinants -poor maternal health/nutrition { -illness -inadequate feeding and care Can have both infant-child - Recent-severe weight loss -inadequate intake/PEM -w/wo infection 4.1.1 4.1.2 Excess E beyond energy needs Low PA (1) (1) 2021 WHO 55 thinness (2) (1) Figure 4.1 Global Americas 60 50 Prevalence (%) 40 30 20 10 0 1990 1994 1998 2002 2006 2010 2014 2018 2022 1990 1994 1998 2002 2006 2010 2014 2018 2022 1990 1994 1998 2002 2006 2010 2014 2018 2022 1990 1994 1998 2002 2006 2010 2014 2018 2022 1990 1994 1998 2002 2006 2010 2014 2018 2022 1990 1994 1998 2002 2006 2010 2014 2018 2022 1990 1994 1998 2002 2006 2010 2014 2018 2022 (2022) Global Americas a 30 Prevalence (%) 20 10 0 a Source (1) WHO 2024 56 15  WHO 58 - Affects food supply ! Globalization * know & Globalization (defined for KOF index of globalization): the process of creating networks of connections among actors at multi- - continental distances, mediated through a variety of flows including people, information and ideas, capital and goods. It is a process that erodes national boundaries, integrates national economies, cultures, technologies and governance and produces complex relations of mutual interdependence. https://www.statista.com/statistics/268168/globalization-index-by-country/ 59 16  Is * Canada is highly globalized-top https://www.statista.com/statistics/268168/globalization-index-by-country/ 60 meansente for 62 17  Globalization and Food Policy- Contribution to NCD’s Rapid changes in diets and lifestyle has total n Industrialization: technology Contina Food industry control of food supply n of processed food ! (ingredients, markets, UPF) n Urbanization n Economic development n Increased female formal labor force participation outside of home n Market globalization – -Food is commodity for world trade -Global vertical integration -Global outsourcing -Global marketing Especially impacting health and nutritional status of populations in developing countries and countries in ‘nutritional transition’ – low and middle income countries - 63 Urbanization and NCD’s Africa and Asia rapid rise in urbanization – 50% 60% of the world population will be urbanized by 2030 Rapid urbanization-population → overcrowding, poor access to food, safe drinking water, sanitation, housing, health care → infectious disease transmission and NCD’s Urbanization of rural towns too. 64 18  How has diet changed? n Major modification in second half of the twentieth century and nutrition-transition n ‘The nutrition transition refers to the shift from traditional diets composed of whole foods, such as pulses and whole grains, and that are low in animal-source foods, salt, and refined oils, sugars, and flours, to an energy-dense and nutrient-poor diet composed of refined carbohydrates, high fat intake, and processed foods’ n HIGH energy-dense diets with low macro-micro nutrient density and Ultraprocessed foods. fortification n Increase risk of NCD:obesity, diabetes, CVD, folate high cancer ex : - leads to higher cancer incidents because not counteract ! n Increased risk of micronutrient deficiencies B12 to enough n Decreased PA (Ford et al 2017, Popkin 2021) 65 Phases on Nutrition Transition 1467789x, 2022, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13366 by University Of Alberta, Wiley Online Library on [08/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-con POPKIN AND NG 3 of 18 Highproportion one · Of transitioned countriea s - UPF and plastics FIGURE 1 Stages of the nutrition transition (Popkin 2021, Yates et al 2024) (4) nutrition-related chronic diseases, and (5) behavioral change. While Stage 1—collecting food: All but a few remote groups have passed 66 most countries appear to have gone through all these states of the the Paleolithic period of collecting food. These hunters and gatherers nutrition transition, there are some that by passed a stage, for exam- had diets which were quite diverse and balanced and those reaching ple, jumping to quickly from the stage of famine to one of rising the age of 20 or older at full height were tall. nutrition-related NCDs. The major features of each are described Stage 2—famine: Diets in this stage were quite simple with mini- below. These stages are neither restricted to periods of human history mal variety in their diet and were subject to episodic periods of nor required to be of a specific span of time. Moreover, these shifts extreme food shortage. Scholars hypothesize that this stage was asso- are far more complex than seen by a simple progression in linear fash- ciated with nutritional stress and a reduction in stature, estimated by ion for a nation or even a region or major spatial and socioeconomic (or race-ethnic) subpopulations. For convenience, we outline them in some at about 4 inches, from the earlier collecting food or hunter- gatherer period. Over the past decade famine has been limited mainly 19 the past tense as historical developments. However, the “earlier” to SSA, South Asia, North Korea, and refugees and migrant groups  UPF and plastics (Crino etal 2015, Yates et al 2024) 67 Globalization of Food Supply →→Dietary Convergence and Acculturation êwhole food intake–ééé pre-prepared-highly-ultra-processed packaged foods with similar ingredients n Less nutritious food that is cheaper for consumer n Increased energy density (kcal)foods and/or total food intake n Corn: HFCS (industry corn subsidies) n Sugar and Refined simple CHO (industry subsidies) n Salt n Vegetable Oils: Trans/SFA transition - (increased soybean, palm and canola use in food products) n Animal products n Fast food and supermarket chains: global increase n Global sourcing of ingredients???? ↳ We don't eve n know where ingredients come from Popkin et al 2021 68 20  How has diet changed? n Other major modifications n Portion size Supersize 1467789x, 2022, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13366 by University Of Alberta, Wiley Online Library on [08/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License POPKIN AND NG n 5 of 18 prevalence of individuals with overweight/obesity in the 1990s and nutrients (e.g., fruits, vegetables, beans, and other complex carbohy- 2010s. We use Demographic Health Survey data55 when available drates and lower intakes of refined foods, meats, and UPFs. To pro- and NCD Risk Factor Collaboration data when DHS data are not gress to this stage sooner and to shorten/minimize Stage 4, large- 4,56 available. We use a combination of overweight and obesity, scale government programs and policies to promote a healthier food because extensive epidemiological research associates a BMI of 25 or environment that better supports human and planetary health is criti- even lower with the risks of NCDs across a large proportion of cal. Increased physical activity and reducing sedentary time are also LMICs.11–13,50,57–60 important for promoting better human health but dietary shifts are We have shown in one study of urbanization how communities the central need to reduce the risk of NCDs across the lifecycle, can gain and lose infrastructure, factories, and other aspects of what improve healthy growth, maximize human. constituted a modern society and shift backwards in the transition.42 In other words, for natural or human-made reasons (be it war or shifting investments in manufacturing and other infrastructure), there 2.1 | Inequities in changes in subpopulations with is potential to fall backwards in what is not a true inexorable shift undernutrition, overweight, or obesity toward a diet dominated by ultra-processed foods, drinking less water and more high calorie beverages, and moving much less due to an Most undernutrition has historically occurred among the poor. Nearly, array of technological changes. The degree of heterogeneity in just all countries saw declines in child wasting or stunting, and a third one component—food processing—is laid out in a detailed paper on experienced annualized declines of more than 1 percentage point per 6 the transition underway in SSA. year from the 1990s to the most recent surveys, though we do not 70 The transition into stage 4 represents a clash between our biology have data on the impact of COVID-19 and all the related social and and modern food science and technology. For instance, we need to economic changes on hunger and stunting or on overweight/obesity drink water at least every 2 to 3 days, but we can survive without discussed below (sample described in Table S3 and data provided in food for 1 to 2 months. By evolving our metabolic system such that Tables S4 and S5). drinking water does not interfere with episodic food intake (and possi- As we present data on prevalence of individuals with overweight/ bly gorging of food), humans were able to survive and thrive through obesity, we must remember that Hispanics, South and Southeast early hunter-gathers experienced periods with sporadic or seasonal Asians, and most individuals in Arabic countries, among others, have hunger. However, consumption of the highly palatable beverages with more central body fat and are more likely to experience significant added sugar or 100% fruit juice that have replaced a notable amount increases in the risks of hypertension, diabetes, and other NCDs at Nutrition Transition Mismatch of the water previously consumed increases weight gain and the risks lower BMIs such as a BMI of 23–25 kg/m2. We consider a 25 kg/m2 of NR-NCDs, with little substitution away from solid foods. Figure 4 BMI cut-off because extensive epidemiological research associates - summarizes the conflicts between modern technology and our biology BMI of 25 kg/m2 - or even lower to the risks of NCDs across over millennia. with our Evolutionary Biology Stage 5—behavioral change: In this stage, food consumption LMICs.11–13,50,57–60 This is why we combined both overweight and obesity together. * have not reverts towards whole and minimally processed foods that resembles We the Demographic and Health Survey individual data from 1990s dietary intakes in stage 1 with higher share of plant-based foods and adaptedin all and the 2010s show an annualized growth in overweight to our food ! supply new We are biologically so old but transitioned only 200yrs ! ago < food companies of advantag e take ! these things z usuallymorea t F I G U R E 4 Role of our history: - Chips ! Biology which evolved over millennia clashes with modern technology (Core biochemical and physiologic processes have been preserved from those who appeared in Africa between 100,000 and 50,000 years ago) (Popkin 2021) 71 21  Nutrient Deficiency and Health 72 Globalization and Food Policy Need to change: advocated Food systems X We can = -production and processing (UPF) Food policy -pricing, marketing, labelling -food composition, supply -trade and distribution Food intake Food Ultra Processed -dietary habits, UPF consumption - -food based dietary guidance -consumption and waste Advocacy: Be part of the solution Re-establish traditional-local farming-seasonal- sourcing of food ingredients, home-cooking èto change disease outcomes 73 22  WHO life-course model of non-communicable disease and Developmental Origins of Adult Disease n Risk positively accumulates throughout the life-course, and disease becomes more prevalent, manifesting in later life. (Yajnik and Deshmukh, 2008) & 75 ① In a few we e ks in m o re detail * Wells et al 2019 76 23  Nutrition & Chronic Disease n Concept of reducing risk and preventing chronic disease by diet n WHO emphasis on chronic disease prevention, late 80’s 78 Nutrition & Chronic Disease n Why the focus on prevention of chronic disease? n Increased prevalence (particularly with age) n Increasing portion of the population that is over 65 yr -Aging population ! n Significant morbidity, mortality & cost n We don’t have a cure - 79 Age composition of the population 24  Prevention Chronic Disease n Unmodifiable Factors: Age, sex, genetic susceptibility (not modifiable at this time) n Modifiable Factors n Diet-Behaviour-lifestyle risks are potentially modifiable n Physical inactivity n Tobacco use n Alcohol consumption n Dietary habits (epigenetics) cancorrect allothea n Biological-Metabolic (dyslipidemia, hypertension, body weight, IR) n Social determinants of health: including access to medical technology, preventative/treatment health care, education, SES (socioeconomic/cultural/environmental/political) 80 Nutrition Chronic Disease - Global Issue n Led by WHO and the Food and Agriculture Organization of the United Nations (FAO), the UN Decade of Action on Nutrition calls for policy action across 6 key areas: creating sustainable, resilient food systems for healthy diets; providing social protection and nutrition-related education for all; aligning health systems to nutrition needs, and providing universal coverage of essential nutrition interventions; Don't have * Canada in ensuring that trade and investment policies improve nutrition; building safe and supportive environments for nutrition at all ages; and strengthening and promoting nutrition governance and accountability globally. * *Acknowledging social determinants of nutrition and health https://www.who.int/news-room/fact-sheets/detail/malnutrition WHO 2016-2030 82 25  WHO: Millenial Development Goals to Sustainability Development Goals By 2030 - highly related to nu. tr 83 WHO Global Nutrition Targets - number of children S who a re stunted ! 84 26  still World health statistics 2024: monitoring health for the SDGs, Sustainable Development Goals going up ! WHO 85 (3, 4) (5) WHO Triple Billion Targets (5) (6) Figure 3.1 Healthier populations 1000 1000 1520 1500 777 Number of people (millions) 1215 750 750 585 599 1000 500 500 429 & estimating 500 met we 250 * Did not 250 * Did not meet meet 0 0 0 2018 2019 2020 2021 2022 2023 2024 2025 2018 2019 2020 2021 2022 2023 2024 2025 2018 2019 2020 2021 2022 2023 2024 2025 Source (5) The world is off track to achieve the triple billion 3.1 targets by 2025 https://www.who.int/publications/i/item/9789240094703 87 27  Prevention and Management of Chronic Disease & We can e advocate all these levels ! 88 Eat Well Live Well with Canada’s Food Guide https://food-guide.canada.ca/en/ 89 28  Disease Risk Reduction Health Claims = Well-established link between nutrient and reduction of risk of developing diet-related disease: 1. A healthy diet low in saturated and trans fats may reduce the risk of - heart disease ↳ typematters Dairy Sat fata ! not ok ! 2. A healthy diet with adequate calcium and vitamin D, and regular physical activity, helps to achieve strong bones and may reduce the risk of osteoporosis 3. A healthy diet rich in vegetables and fruit may help reduce the risk of some types of cancer 4. A healthy diet containing foods low in sodium and high in potassium may reduce the risk of high blood pressure, a risk factor for stroke and heart disease 5. Reduction in dental caries/does not promote dental caries 90 https://www.canada.ca/content/dam/phac-aspc/documents/services/reports-publications/health-promotion-chronic-disease- prevention-canada-research-policy-practice/vol-39-no-10-2019/EN_2_Varin.pdf 91 29  hasals - - - 92 Progressive Food Policy 1467789x, 2022, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13366 by University Of Alberta, Wiley Online Library on [08/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; 10 of 18 POPKIN AND NG & ! Chile F I G U R E 8 Impact of Chilean policies: Key findings after year 1 (during phase 1: Least-restrictive nutrient and energy thresholds). Graphics In created using resources from Flaticon.com ↳ *Black warning label: cut-offs in added sugar, fat, Na *Marketing restrictions phase increased the advertising restrictions to include all media from sectors likely to be affected by the regulations.149 This shows that *School sale 6 a.m.bans to 10 p.m. with warning messages outside those hours so it reformulation was important, particularly for sodium and added sugar = would cover UPF advertising as Chilean ads for UPFs shifted from and that consumers found other healthier options.150 Future publica- Brazilian “kids” example: schools to “adult” shows. must use local farm produce, 75% of school tions willmeal funds elucidate mustamong the shift be spent onhigh-in formerly unprocessed or products toward & minimally processed The impact foods andphase of the first setswas a maximum strong. After of the20% initial on processed imple- foods,sweeteners, nonnutritive and banned SSB adverse effect on sweetness a potential mentation of the law focus groups of low- and middle-income preference.151 mothers reported profound changes in attitudes toward food pur- Evaluations of the second and third implementation phases are 99 chases driven both by the knowledge mothers gained from the labels underway, but the initial results suggest large impacts on purchases and by children telling their mothers not to purchase products with and the nutritional profile of food available. Chile is not the only coun- 141,142 warning labels. Chile'sthis warningi nlabels have been associated with try innovating regulations. Israel has adopted many of the same poli- Why aren't Canada ? Not doing advocating we a roughly 24% drop in sugary drink purchases in the year following cies, but they are not coordinated to be mutually reinforcing in the isn't listening 143 enough you implementation. the initial Importantly, households with lower edu- same way.152 Many countries (e.g., Israel, Mexico, Brazil, and Peru) ,... , cated heads show similar absolute reductions in sugary drinks with have adopted FOP warning labels similar to Chile's, but to date no warning labels as households with higher educated heads, demon- others have linked marketing, and school food, and marketing within strating the these warning labels were understood and did not widen schools to label policies. disparities.24,143 Monitoring of television advertising and surveys of children and Food procurement policies: Brazil has established food procure- ment and feeding policies that will be impactful. While many coun- 30 their parents conducted annually show that the percentage of ads tries have banned sugar-sweetened beverages (SSBs) and food  affect May Shelf life ! ↓ Reformulation of food supply = ↳ ReduceSodiumbutthen usuaa sa ! (Crino et al 2015) 100 * 101 31  be to provide & Would awe s o m e incentives for fresh food/ unprocessed/minimally processed foods ! https://nutrition.tufts.edu/sites/default/files/documents/FIM%20Infographic-Web.pdf 105 Indigenous view of Food as Sacred-Medicine In Indigenous worldviews, there is a sacredness—a spirit— that exists in all things, including our food, and each aspect of Creation is given instructions to follow. Animals, plants, and water all have a responsibility to nourish humans, and we have a reciprocal responsibility to protect, honour, and preserve them. “Food has a culture. It has history. It has stories, it has relationships that tie us to our food. Food is more than something you just buy at the store. Something that doesn’t just have a stamp on it.” Food is Our Medicine | Learning Journey Winter: Ways of Relating | 5 https://www.youtube.com/watch?v=pHNlel72eQc Reclaiming indigenous food relationships and sovereignty to improve health with culture https://www.youtube.com/watch?v=SF9c22zXYR0 106 32  Nutrition Research, Prevention and Treatment NCD 108 Gonzalez et al 2021 116 33  Conclusions n Non-communicable disease > 50% of global morbidity and mortality n Nutrition transition or acculturation and chronic disease is a global problem n Globalization: effect on food supply and diet-related diseases n Sustainable Development Goals/Triple Billion targeting whole global society to target NCD’s (WHO). n Advocacy and research n Research into food-nutrition-diet and metabolic targets in chronic disease and population health 118 34